CMS Proposes 2007 Outpatient Payment Rates

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Under a proposed rule for 2007 Medicare payments for hospital outpatient services released this week by the Centers for Medicare and Medicaid Services (CMS), reimbursement for many blood products and services would continue to lag behind actual costs, despite some proposed payment increases. In general, the agency has proposed modest payment increases for most frequently transfused blood products, but notable payment cuts for other less frequently transfused products.

For calendar year (CY) 2007, CMS has proposed payments for blood and blood products based on simulated medians calculated using CY 2005 hospital claims data. For example, CMS proposes to pay $176.89 for a unit of leukocyte-reduced red blood cells (RBCs), compared with its $163.33 payment in 2006. The actual average hospital acquisition cost for a unit of leukocyte-reduced RBCs is significantly higher than CMS’ proposed 2007 payment. The following table compares the proposed 2007 payment rates for blood products with current Medicare payment rates.

Payments for Blood Components

HCPCS

Description

2006 FinalPayment

2007 Proposed Payment

% Change

P9010

Whole blood for transfusion

$118.04

$134.33

14%

P9011

Blood split unit

$82.59

$135.95

65%

P9012

Cryoprecipitate each unit

$47.15

$52.76

12%

P9016

RBC leukocytes reduced

$163.33

$176.89

8%

P9017

Plasma 1 donor frozen w/in 8 hr

$70.47

$71.87

2%

P9019

Platelets, each unit

$51.55

$60.28

17%

P9020

Platelet rich plasma unit

$277.73

$155.95

-44%

P9021

Red blood cells unit

$121.61

$129.53

7%

P9022

Washed red blood cells unit

$189.42

$215.60

14%

P9023

Frozen plasma, pooled, sd

$76.23

$55.77

-27%

P9031

Platelets leukocytes reduced

$98.41

$94.28

-4%

P9032

Platelets, irradiated

$86.64

$128.99

49%

P9033

Platelets leukoreduced irrad

$150.74

$130.44

-13%

P9034

Platelets, pheresis

$434.48

$463.98

7%

P9035

Platelet pheres leukoreduced

$493.66

$488.80

-1%

P9036

Platelet pheresis irradiated

$326.22

$412.14

26%

P9037

Platelet pheresis leukoreduced, irrad

$581.64

$614.53

6%

P9038

RBC irradiated

$147.63

$200.66

36%

P9039

RBC deglycerolized

$343.81

$351.49

2%

P9040

RBC leukoreduced irradiated

$218.27

$227.97

4%

P9041

Albumin (human), 5%, 50ml

$29.68

$25.48

-14%

P9043

Plasma protein fract, 5%, 50ml

$68.02

$24.72

-64%

P9044

Cryoprecipitate reduced plasma

$74.60

$79.95

7%

P9045

Albumin (human), 5%, 250 ml

$76.81

$72.09

-6%

P9046

Albumin (human), 25%, 20 ml

$28.80

$26.79

-7%

P9047

Albumin (human), 25%, 50ml

$65.26

$61.77

-5%

P9048

Plasmaprotein fract,5%,250ml

$316.05

$192.71

-39%

P9050

Granulocytes, pheresis unit

$995.72

$252.54

-75%

P9051

Blood, l/r, cmv-neg

$207.95

$135.36

-35%

P9052

Platelets, hla-m, l/r, unit

$610.14

$646.80

6%

P9053

Plt, pher, l/r cmv-neg, irr

$654.84

$720.30

10%

P9054

Blood, l/r, froz/degly/wash

$262.21

$89.02

-66%

P9055

Plt, aph/pher, l/r, cmv-neg

$526.57

$378.59

-28%

P9056

Blood, l/r, irradiated

$178.56

$133.97

-25%

P9057

RBC, frz/deg/wsh, l/r, irrad

$345.91

$425.87

23%

P9058

RBC, l/r, cmv-neg, irrad

$267.18

$263.55

-1%

P9059

Plasma, frozen between 8-24hr

$74.78

$73.02

-2%

P9060

Fresh frozen plasma donor retested

$94.82

$73.34

-23%

CMS has also proposed increasing the payment for APC 0112, which covers apheresis, photopheresis and plasmapheresis, from $1569.60 in 2006 to $1887.17 in 2007. However, the agency would modestly decrease payments for bone marrow harvesting and bone marrow/stem cell transplant (APC 0123), transfusion (APC 0110), and blood product exchange (APC 0111), as indicated in the following table.

Procedure Payments

APC

Product/Service

2006 Final Payment

2007 Proposed Payment

% Change

0110

Transfusion

$216.73

$212.78

-1.8%

0111

Blood Product Exchange

$718.70

$720.18

0.2%

0112

Apheresis, Photopheresis, and Plasmapheresis

$1569.60

$1887.17

20.2%

0123

Bone Marrow Harvesting and Bone Marrow/Stem Cell Transplant

$1456.95

$1431.00

-1.8%

Overall, the rule includes a 3.4% inflation update in Medicare payment rates for services paid under the outpatient prospective payment system for 2007. However, for the first time the agency proposes to tie the outpatient payment rate update to the reporting of inpatient quality measures. Hospitals that are required to report quality measures for inpatient services in order to receive the full inpatient prospective payment system (PPS) update but fail to do so would receive the outpatient PPS update minus 2.0 percentage points.